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Time Based Coding Documentation

  1. Default Time Based Coding Documentation
    Medical Coding Books
    Opinion poll on sufficient documentation for a time based visit. Physician documents the History and Exam portions, here is the and Assessment/plan:

    Assessment:
    625.6, 620.2

    Orders:
    CA125
    Plan:
    1. RT office one month for repeat TVUS to evaluate for stability/resonlution of ovarian cyst
    2. Multichannell urodynamics for evaluation of incontinence
    3. Have discussed inability to guarantee absence of malignancy short of surgical resection- pt declines at this time- Have notified pt that I doubt cyst as cause of symptoms due to small size.
    Time spent with patient was 30 minutes with more than 50% of time spent on counseling and coordination of care.


    Is the documentation sufficient for billing on time? He does state what he discussed in #3 under plan of care. Or would it need to be specifically stated after the statement of "Time spent with patient was 30 min...."? Would #3 be considered plan of care and does not qualify as documentation for time based visit? Guidelines do not give examples of topics that are considered counseling (test results, treatment options, risks, etc)

    Opinions???

  2. #2
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    Quote Originally Posted by dadams6871 View Post
    Opinion poll on sufficient documentation for a time based visit. Physician documents the History and Exam portions, here is the and Assessment/plan:

    Assessment:
    625.6, 620.2

    Orders:
    CA125
    Plan:
    1. RT office one month for repeat TVUS to evaluate for stability/resonlution of ovarian cyst
    2. Multichannell urodynamics for evaluation of incontinence
    3. Have discussed inability to guarantee absence of malignancy short of surgical resection- pt declines at this time- Have notified pt that I doubt cyst as cause of symptoms due to small size.
    Time spent with patient was 30 minutes with more than 50% of time spent on counseling and coordination of care.


    Is the documentation sufficient for billing on time? He does state what he discussed in #3 under plan of care. Or would it need to be specifically stated after the statement of "Time spent with patient was 30 min...."? Would #3 be considered plan of care and does not qualify as documentation for time based visit? Guidelines do not give examples of topics that are considered counseling (test results, treatment options, risks, etc)

    Opinions???
    The way the time is documented would qualify to use Time as a controlling factor in determining the E/M code.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

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